Every finding on record at Porthaven Post Acute

Based on interview and record review it was determined the facility failed to promptly respond to grievances and complaints from the resident council for three of four months reviewed. This placed residents at risk for a lack of resolution to voiced concerns. Findings include:An undated facility Resident Council Policy indicated the following:-A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. -The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review. -Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.). A review of the 1/2025 through 11/2025 grievance book revealed that there were no grievances submitted by the Resident Council. A review of the Resident Council Minutes from 8/2025 through 11/2025 revealed multiple concerns including but not limited to call light wait times, lack of adequate CNAs on the floor, language barrier and dietary concerns brought up from the resident council which included old and new business. No evidence was found concerns or grievances were addressed.During the 12/3/25 2:30 PM interview with the Resident Council members, seven of the twelve residents in attendance (#s11, 15, 21, 30, 44, 52, and 82) stated concerns and suggestions brought up during Resident Council were not followed up or addressed by the facility beyond talking to the department head.On 12/4/25 at 8:47 AM, Staff 14 (Activity Director) stated, she spoke at Resident Council regarding old business to see if the residents' view had changed or there were changes with the concerns. Staff 14 stated she brought the resident council's concerns and suggestions to the administrator who would go to each department head to speak to them to come up with a plan. On 12/5/25 at 1:57 PM Staff 1 (Administrator) stated concerns from Resident Council were separated, and Staff 15 (Social Services Director) managed grievances. Staff 14 was responsible for documenting concerns, notifying relevant departments, following up on outcomes, and reporting back to the Resident Council. Staff 1 acknowledged the need for a more effective process to address concerns and emphasized the importance of timely communication and updates to the Resident Council and completion of timely grievances. On 12/5/25 1:57 PM Staff 15 stated grievances from Resident Council were on a separate form, and she did not receive any grievances from Staff 14 or Resident Council. She stated Staff 14 followed up on Resident Council grievances and was a separate process. She stated Staff 14 followed up on the Resident Council grievances with a separate process that did not go through the social services department.

Based on observation, interview, and record review it was determined the facility failed to provide a clean and sanitary environment toilet/shower rooms for 3 of 4 communal resident bathrooms reviewed for homelike environment. This placed residents at risk for unsanitary conditions while using the communal toilet/shower rooms. Findings include:The facility's policy titled Cleaning and Disinfection Environment Surfaces, adopted on 8/1/24 indicated the following: Policy: Environmental surfaces are cleaned and disinfected according to CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. A one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes is used in resident care areas where: a. uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt) or b. uncertainty exists about the presence of multi-drug-resistant organisms on such surfaces.Resident 11 admitted to the facility on [DATE] for atherosclerosis of the left lower leg with ulceration and right above knee amputation. The MDS dated [DATE] revealed Resident 11's BIMS score was 15, which indicated she/he was cognitively intact. The resident was independent with toilet hygiene and toilet transfers.In an interview with Resident 11 on 12/2/25 9:18 AM she/he stated the communal toilet/shower rooms smelled and often had feces on the toilet seats. Resident 11 stated she/he used multiple communal toilet and shower rooms for toileting and showering.Random observations of communal toilet/shower rooms from 12/2/25 through 12/5/25 revealed the following:*12/2/25 at 10:58 AM a CNA placed a shower chair in the communal shower room across from room [ROOM NUMBER] and room [ROOM NUMBER]. [NAME] material was on the inside edge of the toilet. and a strong urine odor. A crumpled-up paper towel was under the shower chair with bits of paper just outside the shower mat. Multiple staff were in and out of the communal shower without cleaning the area.*12/2/25 at 11:10 AM the communal shower across from room [ROOM NUMBER] had a reclining shower chair with an approximately one-inch smear of brown material on the seat and crevasses where the commode basin would fit.*12/3/25 at 9:16 AM through 9:36 AM the communal shower across from room [ROOM NUMBER] had the same reclining shower chair and the brown material was still on the seat and crevasses. The reclining chair was moved by Staff 18 (CNA) but she did not clean the chair after usage with another resident and the brown material remained.*12/3/25 at 9:46 AM Staff 18 pushed a resident out of the communal shower room across from room [ROOM NUMBER] in a shower chair. The shower room door was left open and unclean, with saturated towels, washcloths and brown material on the shower room floor and matted hair on the grab bar. A sign was posted in the shower area which indicated after each shower provided to residents not to leave towels or clothes, empty trash cans, and keep shower room clean and ready for other residents to use. At 9:54 AM Staff 18 returned to the communal shower, sprayed the area with the shower nozzle but did not disinfect the area.*12/3/25 at 10:11 AM Staff 18 walked a resident down to the communal shower across from room [ROOM NUMBER] and closed the door. At 10:40 AM Staff 18 left the shower room and left the door open. The shower had an odor of bowel movement and brown material was on the shower floor. At 10:43 AM Staff 7 (CNA) entered the shower room sprayed the soiled area with water and did not disinfectant the communal shower. At 12:04 PM the shower chair had dried brown material on the seat, and the shower area was unclean.*12/3/25 at 11:00 AM Staff 7 returned to the toilet/shower room across from room [ROOM NUMBER] to finish cleaning. Staff 7 left the communal shower area, and the brown smear remained on the toilet seat and crumpled paper was on the floor.*12/3/25 at 12:04 PM the bath/shower room across from room [ROOM NUMBER] had the same brown smear on the toilet seat and crumpled paper on the floor. The shower chair still had dried brown material on the seat.*12/4/25 at 12:31 PM and at 3:40 PM the toilet/shower room across from room [ROOM NUMBER] was unclean. The toilet seat and bowl had brown smears and a shower chair with brown smears was in front of the sink. The door of the room was left open.*12/4/25 at 5:48 PM on and on 12/5/25 at 7:04 AM the toilet in the communal shower room across from room [ROOM NUMBER] had the same brown smears on the toilet seat. On 12/3/25 at 10:46 AM, Staff 7 stated after completing a shower, staff either dressed the resident in the shower room or assisted them back to their room in a shower chair before returning to clean up. Staff 7 stated a disinfectant spray bottle was located in the utility room was available for cleaning the shower chair, but she did not use the disinfectant. She stated the facility had not provided specific guidance for cleaning the floor and mats, so she typically used the shower sprayer and, sometimes added shampoo or soap. Staff 7 confirmed when bowel incontinence occurred, she used a washcloth with soap to wipe surfaces and sprayed feces down the drain. Staff 7 stated staff were expected to disinfect the shower with a chemical spray before the next use, she acknowledged she had not done so. She stated if the bath/shower room was not clean, staff were instructed to close the door to prevent resident use before cleaning.On 12/4/25 at 12:46 PM Staff 23 (Housekeeper) stated there was a problem with CNAs not cleaning the bathroom, between when housekeepers deep cleaned. She stated after CNAs completed showers, they would often only pick up the residents' items and leave everything else. She reported these concerns to management, but nothing happened. She stated it was a safety concern when residents use dirty bathrooms. Staff 23 stated we are supposed to clean it in the moment and housekeeping cleaned the bath/shower rooms at least daily but sometimes multiple times in a day when CNAs asked. She stated the door was supposed to remain closed when unclean and if open, the bathroom was available for resident use. In an interview on 12/4/25 at 1:04 PM Staff 16 (Housekeeping Manager) confirmed the communal toilet/shower rooms were cleaned by housekeeping at least daily, more if needed. She stated CNAs should check the bathroom after independent residents used the bathroom and were expected to clean and sanitize after each resident. Staff 16 stated communal toilet/shower room doors were to stay closed until the room was cleaned but at times residents utilize the communal toilet/shower room before being cleaned and sanitized appropriately. Staff 16 stated if housekeeping staff came to her with complaints, she reported concerns to the nurses. On 12/4/25 at 4:01 PM Staff 19 (CNA) stated when asked about the cleaning process after showers, I am not a housekeeper, I am a CNA. What I bring to the shower room, I bring out and put the shower chairs back in a safe place. Staff 19 stated she would put the yellow sign out to let others know the room was not available and housekeeping had the chemicals to clean the shower rooms. Staff 19 stated she sprayed the shower chairs with water but sometimes used the soap in the room. She stated if the toilet was dirty before she brought a resident into the shower room, she would put on gloves and clean it with hot water, paper towels or a washcloth. She stated housekeeping cleaned the communal toilets once per day or she called them to clean the toilet if they looked unclean.On 12/5/25 at 7:12 AM Staff 2 (DNS) confirmed the communal toilet/shower room across from room [ROOM NUMBER] was unclean with feces on the communal toilet and she acknowledged the communal toilet/shower rooms should not have been left uncleaned. Staff 2 stated CNAs were expected to clean the toilet and shower chairs when they were unclean. She stated staff had access to a disinfectant spray, which they were supposed to use. Staff 2 stated housekeeping rounded and were to clean areas considered high-risk surfaces and clean the communal bath/shower rooms.

Based on observation, interview and record review it was determined the facility failed to develop and implement a resident-centered activity program for 1 of 2 sampled residents (#42) reviewed for activities. This placed residents at risk for a diminished quality of life. Findings include:The facility's 6/2018 Activity Programs Policy indicated activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident and documented in the resident's medical record. Resident 42 was admitted to the facility in 10/2025 with diagnoses including dementia.Resident 42's 10/29/25 admission MDS revealed the resident was mildly cognitively impaired and listening to preferred music was a very important activity to the resident. The Activities CAA indicated an activity care plan would be created and updated as needed. Resident 42's Activity Task Records from 11/9/25 to 12/8/25 revealed the resident did not participate in any music-themed activities. A review of Resident 42's clinical record revealed no activity care plan was developed for the resident. Random observations of Resident 42 from 12/2/25 through 12/5/25 between 8:44 AM to 2:55 PM revealed the resident was in her/his room in bed. No music was observed to play in the resident's room. On 12/3/25 at 11:12 AM, Resident 42 stated she/he preferred to spend her/his time in her/his room. Resident 42 stated she/he loved to listen to music, especially Christmas music, and had not been able to do so since her/his admission to the facility. On 12/8/25 at 7:11 AM, Staff 11 (CNA) stated she did not know Resident 42's activity interests, including if the resident liked music. Staff 11 stated she looked in the care plan to learn about a resident's activity interests. On 12/8/25 at 7:21 AM and 12:25 PM, Staff 12 (CNA) stated Resident 42 spent all of her/his time in her/his room, and the resident did not have any activity interests. Staff 12 further stated she had never heard music on in the resident's room. On 12/8/25 at 8:01 AM and 12:13 PM, Staff 13 (CNA) stated she did not know Resident 42's activity interests, but she would look in the resident's care plan to find the information. On 12/8/25 at 8:16 AM and 1:00 PM, Staff 7 (CNA) stated she did not know Resident 42's activity interests, and she had never heard music play in the resident's room. Staff 7 stated she was not sure if activity interests were listed in resident care plans.On 12/8/25 at 11:47 AM, Staff 14 (Activity Director) stated she completed activity interest interviews with residents shortly after their admission to the facility and added this information to resident activity care plans. Staff 14 stated music was a big activity for Resident 42, but she did not know which type(s) of music the resident preferred. Staff 14 stated Resident 42 should have an activity care plan in place, which included her/his musical preferences, but acknowledged the resident did not have anything listed on the care plan.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 6 residents (#14) reviewed for unnecessary medications. This placed residents at risk for decreased weight loss. Findings include:Resident 14 was admitted to the facility in 10/2025 with diagnoses including an open wound on her/his right foot and morbid obesity.Resident 14's 10/12/25 admission MDS revealed she/he had moderate cognitive impairment and was dependent for bed mobility, transfers and toileting hygiene.Signed physician orders dated 10/14/25 revealed Resident 14 was to receive 0.5ML of Tirzepatide injected subcutaneously every seven days for diabetes mellitus and weight management.A review of Resident 14's medication administration records revealed she/he did not receive an injection of Tirzepatide as ordered on the following days:-11/19/25-11/26/25-12/3/25A progress note created on 11/19/25 revealed Resident 14 was given her/his final weekly dose and a new order was placed for her/his next dose.On 12/3/25 at 9:57 AM Resident 14 stated, she/he started receiving the Tirzepatide as ordered on 10/14/25 and received weekly doses until 11/13/25. Resident 14 stated the medication was important to her/him because it would help her/him lose weight so she/he could participate in therapy and improve her/his strength and overall health. Resident 14 stated she/he did not know why the facility ran out of the Tirzepatide and thought it might be related to the cost of the medication.On 12/4/25 at 9:34 AM Staff 4 (LPN) stated she was aware Resident 14 missed doses of Tirzepatide and the refill was awaiting approval. Staff 4 stated the delay may have been because the pharmacy ran out or because it was a high-cost medication.On 12/4/25 at 9:48 AM Staff 6 (LPN-Resident Care Manager) stated she was aware Resident 14 missed three doses of Tirzepatide. Staff 6 stated the pharmacy was looking for an alternative because it was a high-cost medication. Staff 6 stated she expected Resident 14 to receive all of her/his medications as ordered by the physician.On 12/4/25 at 10:23 AM Staff 2 (DNS) stated the facility had a contingency plan to call the pharmacy and have medications statted to the facility if they ran out of a resident's medications. Staff 2 also stated she expected staff to call the physician for an alternate medication in the interim, but this plan was not followed. Staff 2 stated she was aware Resident 14 missed doses of Tirzepatide and she expected residents to receive medications as ordered by their physicians.

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for 1 of 1 sampled resident (#42) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions. Findings include: The facility's 7/2017 Resident Mobility and ROM Policy indicated the following:-Residents with limited ROM received treatment and services to increase and/or prevent a further decrease in ROM.-As part of the comprehensive assessment, the nurse identified conditions that placed the resident at risk for complications related to ROM and mobility, including contractures. -The care plan would be developed based on the comprehensive assessment and revised as needed. -The care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. -Interventions included therapies, the provision of necessary equipment, and/or exercises and would be based on professional standards of practice and be consistent with state laws and practice acts. -The care plan would include the type, frequency and duration of interventions, as well as measurable goals and objectives. Resident 42 was admitted to the facility in 10/2025 with diagnoses including dementia and hemiplegia (paralysis on one side of the body).Resident 42's 10/29/25 admission MDS revealed the resident was mildly cognitively impaired and experienced upper and lower extremity impairment on one side of the body. An 11/11/25 Progress Note revealed Resident 42 experienced significant mobility and ADL impairment and persistent right-sided hemiplegia following a stroke.No evidence was found in Resident 42's clinical record to indicate a care plan was developed to address the resident's right-sided weakness. Random observations of Resident 42 on 12/2/25 and 12/3/25 from 8:44 AM to 2:55 PM revealed the resident to be in her/his room in bed. The resident's four fingers on her/his right hand pressed into the palm of her/his hand and the resident's right thumb pushed tightly into her/his right index finger. On 12/3/25 at 11:12 AM, Resident 42 attempted to open the fingers on her/his right hand with her left hand and was only able to slightly raise the index and middle fingers on her/his right hand. The resident stated the facility had done nothing for her/his hand contracture, and she/he was interested in using a rolled washcloth or a therapy carrot (an orthotic device that positions the fingers away from the palm to protect the skin from excessive moisture, pressure and the risk of nail puncture). On 12/4/25 at 12:51 PM, Resident 42 was observed in her/his room in bed. A small piece of rolled gauze was observed in the resident's right hand between her/his fingers and palm. The resident stated she/he was happy to have something placed in her/his hand. On 12/8/25 at 7:16 AM, Staff 24 (CNA) stated she did not know anything about Resident 42's hand contracture or related interventions. On 12/8/25 at 7:21 AM, Staff 12 (CNA) stated Resident 42 did not use her/his right hand, and it stayed curled up. Staff 12 stated she placed rolled gauze in the resident's right hand because she noticed her/his fingers were curled. Staff 12 stated the resident did not have any care plan interventions related to her/his hand contracture, and she often did not see anything placed in the resident's right hand.On 12/8/25 at 7:25 AM, Staff 25 (Director of Rehabilitation and OT) stated a splint had been ordered to be used for Resident 42's right hand contracture, and staff were to place a hand roll in the resident's contracted hand until the splint arrived at the facility. Staff 25 stated he informed one unidentified CNA of this intervention but did not inform other staff or ensure a care plan was created.On 12/8/25 at 7:47 AM, Staff 26 (LPN) stated she was the nurse assigned to work with Resident 42. Staff 26 stated she was unfamiliar with Resident 42 and her/his right-hand contracture. Staff 26 state she would look in the resident's care plan to find information about her/his contracture. On 12/8/25 at 1:41 PM, Staff 27 (Regional RN) stated she expected a care plan to be created and implemented for residents who utilized orthotic devices.

Based on observation, interview and record review it was determined the facility failed to ensure residents received adequate supervision and smoking materials were properly secured for 1 of 2 sampled residents (#73) reviewed for accidents. This placed residents at risk for accidents. Findings include:The facility's 9/2024 Smoking Policy indicated the following:-Residents who do not meet the established criteria to smoke independently are aided/supervised during smoking activities. -Residents are not allowed to borrow cigarettes or other smoking materials from other residents. -All smoking materials are locked up, including smoking materials for residents who are assessed to be a supervised smoker. Resident 73 was admitted to the facility in 11/2025 with diagnoses including intracerebral hemorrhage (brain bleed). Resident 73's 11/26/25 admission MDS revealed the resident was mildly cognitively impaired and did not use tobacco. Resident 73's 12/1/25 Smoking Assessment revealed the resident was cognitively impaired, smoked cigarettes, could not light her/his own smoking device and required supervision when she/he smoked. Resident 73's 12/1/25 Smoking Care Plan directed the following:-The resident required supervision to smoke.-The resident was to wear a smoking apron when she/he smoked.-The resident's smoking paraphernalia was to be stored per facility procedure.On 12/1/25 at 1:51 PM, Resident 73 was observed in her/his room in bed and held an unlit cigarette in her/his left hand. The resident stated a friend at the facility provided her/him with cigarettes.On 12/4/25 at 6:13 AM, Staff 28 (CNA) stated Resident 73 smoked independently at night. Staff 28 stated she did not know where the resident's smoking material was supposed to be stored. On 12/4/25 at 12:39 PM, Resident 73 was observed in her/his room in bed. The resident stated she/he did not wear an apron when she/he smoked, and staff did not supervise or help her/him when she/he smoked but wished they did. On 12/5/25 at 6:14 AM, Staff 29 (CNA) stated she did not know if Resident 73 required supervision when she/he smoked. Staff 29 stated the resident usually went out to smoke with another resident at the facility. On 12/5/26 at 6:20 AM, Staff 30 (CNA) stated Resident 73 smoked whenever at night, she/he smoked independently and did not wear a smoke apron. On 12/5/25 at 6:32 AM, Staff 31 (RN) stated she knew Resident 73 smoked but did not know if staff supervised her/him when she/he smoked.On 12/5/25 at 7:00 AM, Staff 32 (CNA) stated Resident 73 smoked independently, and the resident kept her/his smoking materials in the drawer of her/his nightstand, in her/his jacket or in the pouch on her/his wheelchair. On 12/5/25 at 11:00 AM, Staff 37 (LPN-Resident Care Manager) stated Resident 73 required supervised when she/he smoked and her/his smoking material was to be locked up.On 12/5/25 at 11:01 AM, Staff 2 (DNS) stated she expected Resident 73's care plan to be followed with regards to smoking and her/his smoking material.

Based on observation, interview, and records review it was determined the facility failed to practice proper food safety techniques for 1 of 4 (#5) residents reviewed for food. The placed residents at risk for consumption of contaminated food. Findings include:The Center for Disease Control 11/24/25 Food Safety guidelines include the following information:Bacteria can multiply rapidly if food is left at room temperature or in the Danger Zone between 40 degrees F and 140 degrees F.Never leave perishable food (meat, dairy, and cut fruit) out for more than two hours.Resident 5 was admitted to the facility in 8/2024 with diagnoses including anxiety disorder and PTSD (Post Traumatic Stress Disorder).A Care Plan updated 8/25/25 included interventions for room cleaning including asking resident if room could be cleaned and ensuring safe/sanitation in the room.Review of records revealed no specific information of education provided to Resident 5 on risks of having meals kept in her/his room for extended periods or alternate techniques attempted to ensure Resident 5's safety with food while accommodating for Resident 5's food preferences.On 12/1/25 at 11:34 AM four food trays were observed in Resident 5's room. Three of those trays had full or partially full glasses of milk. Opened yogurt containers were observed on multiple food trays.On 12/4/25 at 1:50 PM Resident 5 stated she/he requested food trays to be left in her/his room. Resident 5 stated she/he often consumed the food and drinks, including her/his milk and yogurt, several hours after meals were delivered. Resident 5 stated she/he occasionally consumer the milk and yogurt overnight.On 12/5/25 at 9:24 AM Staff 36 (CNA) stated Resident 5 often saved food in her/his room overnight.On 12/5/25 at 12:03 PM Staff 16 (Dietary Manager) stated Resident 5 requested food to be left in her/his room often. When asked if Staff 16 provided education to Resident 5 regarding consuming dairy products left out longer than two hours, Staff 16 was unable to provide any records. On 12/8/25 at 12:42 PM Staff 5 (LPN-Resident Care Manager) confirmed Resident 5 preferences regarding food were being honored with leaving her/his meal tray in her/his room for extended periods, but food safety practices were not followed, and no detailed education was provided to Resident 5 regarding the risk of consuming dairy products exposed to room temperature longer than two hours.On 12/8/25 at 12:58 PM Staff 5 entered Resident 5's room and three food trays were observed in her/his room. One tray contained a dish with meat and a glass of milk. A meal ticket was observed on the tray which indicated the meal was from dinner on 12/7/25.

Based on interview and record review it was determined the facility failed to ensure a safe discharge from the facility for 1 of 3 sampled residents (#5) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include:Resident 5 was readmitted to the facility in 2/2025, for congestive heart failure and delusional disorders.On 8/4/25 at 2:40 PM and 8/5/2025 at 4:01 PM, Witness 1 (Primary Physician) stated Resident 5 was discharged unsafely to the resident's family home, which had no running water, rats, and no heat in the winter. Witness 1 further stated the facility had never included them in any discharge planning nor had the facility informed them that Resident 5 was discharged . On 8/6/2025 at 4:20 PM, Witness 2 (former Social Services Director) stated Resident 5 was really discouraged from returning to his/her family home due to unsafe situations, including a rat infestation, no running water, and no electricity.Resident 5's clinical records indicated an IDT meeting was held on 11/17/2024, which stated it was unsafe to discharge Resident 5. Resident 5's Social History Review dated 5/9/2025 indicated Resident 5 wanted to discharge back to her/his family home, which was an unsafe discharge.Resident 5's Discharge Summary, signed on 5/20/2025, indicated the resident was discharged on 5/21/2025 at 11:00 AM to their home/community.There was no documented evidence that the facility's interdisciplinary team met to ensure Resident 5 was safely discharged on 5/21/2025.On 8/7/2025 at 1:01 PM, Staff 2 (Administrator), Staff 5 (Director of Nursing), and Staff 6 (Regional RN Consultant) were informed of Resident 5's unsafe discharge and no additional information was provided.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 resident (#2) reviewed for physical abuse. This resulted in physical injury and prolonged pain which required increased pharmaceutical interventions. Findings include: Resident 2 was admitted to the facility in 4/2023 with diagnoses including multiple spinal fractures and mild cognitive impairment. The 1/9/25 Quarterly MDS, revealed Resident 2 had severe cognitive impairment and was independent with mobility. Resident 1 was admitted to the facility in 11/2023 with diagnoses including restlessness and agitation. A 8/13/24 Quarterly MDS, revealed Resident 1 had severe cognitive impairment and was independent with mobility. An email communication record from 11/30/23 from Staff 19 (Prior Interim DNS) reported Resident 1 was a very violent person with behaviors and provided contact information for Resident 1's probation officer. A review of Resident 1's clinical record including her/his care plan revealed no information regarding her/his violent behavior. A 3/27/25 Progress Note revealed Resident 2 stopped when walking by Resident 1 in the hallway. Resident 1 was observed pushing Resident 2 to the ground and punching Resident 2. Resident 2 reported pain and numbness in her/his right side after the incident. A 3/27/25 Emergency Department Encounter Note reported Resident 2 was determined to have a lumbar spinal fracture, rib pain and difficulty breathing as a result of the incident. A review of Resident 2's pain records (pain scale, which rates pain from 1 to 10, to describe how pain affects daily activity. Mild Pain [1-3], moderate pain [4-6] and severe pain [7-10]) from 3/28/25 through 4/9/25 revealed the following: - 3/28/25 8 out of 10 pain, - 3/30/25 8 out of 10 pain, - 3/31/25 5 out of 10 pain, - 4/1/25 8 out of 10 pain, - 4/2/25 8 out of 10 pain, - 4/3/25 9 out of 10 pain, - 4/4/25 8 out of 10 pain, - 4/5/25 10 out of 10 pain, - 4/6/25 5 out of 10 pain and - 4/9/25 9 out of 10 pain. Review of the 3/2025 and 4/2025 MARs revealed the following medications were provided to Resident 2 to address increased and prolonged pain: - Acetaminophen at 650 mg was received one to two times a day from 3/28/25 through 4/3/25 with a pain level recorded at moderate to severe pain levels recorded upon administration. - Ibuprofen at 600 mg three times a day was received from 3/28/25 through 4/2/25. - Oxycodone at 5 mg was received two to four times a day from 3/31/25 through 4/5/25 with moderate to severe pain levels recorded upon administration. - Fentanyl Patch at 12 mcg was applied on 4/7/25. - Morphine sulfate at .5 ml was provided three times a day on 4/5/25 and 4/6/25. - Morphine sulfate at .25 ml was provided twice on 4/9/25. A 4/3/25 Facility Investigation Summary reported on 3/27/25 at 3:45 PM Resident 1 called Resident 2 a bitch when walking past her/him. Resident 2 asked Resident 1, What did you say? Resident 1 responded by saying, Fuck you, motherfucker and then pushed Resident 2 causing her/him to lose her/his balance, hit the wall behind her/him and fall to the ground. Staff were required to immediately intervene and separate the two residents. A 4/5/25 Progress Note written by Staff 20 (Licensed Vocational Nurse) revealed Resident 2 was experiencing increased confusion and agitation, was refusing to eat, was refusing to take medications and refusing all care. Attempts to contact Resident 1 were unsuccessful and Resident 2 passed away. On 4/15/25 at 10:57 AM Staff 17 (CNA) stated Resident 2 was mostly independent prior to the incident but was bedridden and often screamed out in pain when ADL care and repositioning assistance was provided. On 4/15/25 at 11:22 AM Staff 16 (CNA) stated Resident 2 was thriving before the incident. Staff 16 stated Resident 2 did not like to be touched after the incident due to increased pain. Staff 16 stated Resident 2 regularly walked around the facility prior to the incident but did not continue due to increased and prolonged pain for weeks after the incident. On 4/15/25 at 11:44 AM Staff 12 (Social Service Director) and Staff 13 (Social Services Assistant) stated they collected information regarding the incident. Staff 12 reported Resident 2 was walking by Resident 1 when Resident 1 made an unknown verbal remark towards Resident 2. Resident 2 was hard of hearing and asked for the statement to be repeated, upon which Resident 1 pushed Resident 2 against the wall. This caused Resident 2 to fall to the floor. Resident 1 was observed to be punching Resident 2 which required staff intervention. Staff 12 reported the police were called and Resident 1 was arrested immediately after the incident. Staff 12 and Staff 13 reported Resident 2 experienced increased pain and remained in bed all day. On 4/15/25 at 1:14 PM Staff 11 (RN) stated she witnessed the incident. Staff 11 stated she heard yelling down the hall and observed Resident 1 push Resident 2 down with both hands resulting in a fall to the ground over her/his walker. Staff 11 stated she was required to rush over to separate Resident 1 and Resident 2. Staff 11 stated Resident 2 was on the ground and yelled get me up! get me up, while complaining of pain to her/his ribs. Staff 11 stated Resident 2 appeared in shock immediately following the incident. Staff 11 stated she considered what she observed as assault. During an interview on 4/15/25 at 1:54 PM with Staff 10 (LPN-Resident Care Manager) and Staff 7 (LPN-Resident Care Manager), Staff 7 stated Resident 2 was medically stable prior to the incident. Staff 7 and Staff 10 stated Resident 2 changed from being up and walking around to not getting out of bed after the incident. Staff 10 stated Resident 2 had increased pain and decreased ability to hold a conversation after the incident. Staff 10 confirmed the incident was abuse. On 4/15/25 at 2:47 PM Staff 1 (Administrator) acknowledged Resident 2 was physically abused by Resident 1 on 3/27/25.

Based on interview and record review it was determined the facility failed to accurately document wound assessments and dressing change refusals for 1 of 3 sampled residents (# 3) reviewed for accuracy of medical records. This placed residents at risk for inaccurate medical records and risk for injury and/or decreased ability for recovery. Findings include: Resident 3 was admitted to the facility in 1/2025 with diagnoses including acute and subacute infective endocarditis (infection). An undated facility policy pertaining to documentation indicated the following: - all nursing staff must document resident assessments. - Documentation should be timely, complete and entered in the appropriate PCC module. - Refusals of care are to be documented in the progress notes including interventions used, resident response, and any notifications made. Resident 3 had the following weekly wound assessments documented in her/his medical record: 1/20/25, 1/24/25, 1/30/25, 2/6/25, 2/13/25, 2/20/25, 2/27/25, 3/6/25, 3/7/25, 3/20/25, and 4/7/25. There was no documented assessments found between 3/20/25 and 4/7/25. Weekly wound assessments dated 1/20/25, 1/24/25, 1/30/25, 2/6/25, 2/13/25, 2/20/25, 2/27/25, 3/7/25, and 4/7/25 were found to be incomplete. The assessments were missing all or part of the following: - wound measurements; - wound description; - percentage of slough vs granulation vs epithelial; - type of wound. On 4/9/25 at 7:28 AM, Staff 5 (LPN/Care Manager) stated Resident 3 had refused the last three wound assessments from an outside wound agency. This information was not documented in Resident 3's medical record. On 4/9/25 at 8:03 AM, Staff 3 (RN) stated the nurses were instructed to fill in the assessment form after they had completed their wound assessment. Staff 3 confirmed weekly wound assessments were not fully completed. On 4/9/25 at 8:26 AM, Staff 3 (RN) and Staff 4 (RN) confirmed the weekly wound assessments were incomplete and not all refusals of care were documented appropriately.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 1 of 3 residents (# 2) sampled reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: Resident 2 was admitted to the facility in 3/2025 with diagnoses including open wound to left foot. A 3/20/25 Admission MDS revealed Resident 2 was cognitively intact. On 4/8/25 at 10:00 AM, during an observation of a chronic wound dressing change, an unidentified female placed an enhanced barrier precaution sign on the door to Resident 2's room. Staff 6 (RN) and Staff 5 (LPN/Care Manager) were observed to then put appropriate PPE on and continue Resident 2's dressing change. There was no documentation found in Resident 2's clinical record indicating she/he had been placed on enhanced barrier precautions for a chronic wound. On 4/8/25 at 10:56 AM, Staff 6 confirmed he had not worn appropriate PPE (gown) when he provided care to Resident 2. On 4/8/25 at 10:59 AM, Resident 2 stated she/he had been in the facility since mid-March. Resident 2 stated today (4/8/25) was the first day she/he had seen staff wear PPE gowns when they provided care for her/his chronic wound. On 4/8/25 at 3:05 PM, Staff 5 (LPN/Care Manager) stated normal procedure was to implement enhanced barrier precautions for a chronic wound, catheter, central line, feeding tube, etc. upon admission. Staff 5 confirmed there should have been an enhanced barrier precautions sign posted and appropriate PPE worn.

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 1 sampled residents (#11) reviewed for sexual abuse. This placed residents at risk for psychological harm. Findings include: The facility's Abuse policy, revised 1/2023, stated the facility and staff would protect residents from all types of abuse. The facility's Resident Sexual Consent policy dated 9/2022, stated a resident's consent to engage in sexual activity is not valid if a resident lacks the capacity to consent. Any forced sexual activity with a resident is considered sexual abuse. Resident 10 admitted to the facility 7/2024, with diagnoses including Alzheimer's disease. Resident 10's 8/2024 MDS indicated she/he was cognitively intact. Resident 10 was discharged home on 8/28/24. Resident 11 admitted to the facility 5/2024, with diagnoses including Factor X chromosome (a genetic disorder causing developmental and intellectual disability). Resident 11's Quarterly Minimum Data Set (MDS) indicated the resident had severe cognitive impairment. Review of Resident 10 and Resident 11's clinical record found no evidence a Sexual Consent Form was completed. A Facility Reported Incident (FRI) dated 8/20/24 at 6:30 PM, revealed Resident 10 was observed to be rubbing Resident 11's genitalia in an annexed TV area. Both residents were immediately separated and were assessed for injuries by Staff 5 (LPN) and Staff 6 (RN). No injuries were noted. Observations made on 8/29/24 at 11:05 AM, revealed Resident 10 was discharged . Resident 11 attended meals in the dining room and self-propelled via wheelchair through-out the community. On 8/29/24 at 11:05 AM, Resident 11 was observed in the hallway and self-propelled her/himself via wheelchair to the dining room for bingo. Resident 11 stated she/he was not afraid of any other resident at the facility. On 8/29/24 at 11:20 AM, Resident 12, Resident 13 and Resident 14 all stated they had not been inappropriately touched while residing in the facility. On 8/30/24 at 1:03 PM, Staff 6 stated she was notified by Staff 8 (CNA) a resident was being touched inappropriately by another resident in the TV room. Staff 6 stated the residents were immediately separated, management and providers were notified and both residents were brought back to their individual rooms and placed on alert monitoring. Resident 10 was placed on a 1:1 supervision and Resident 11 had a STOP sign placed on their room door. On 8/30/24 at 1:28 PM, Staff 8 stated on 8/20/24 around 6:10 PM, she witnessed Resident 10's hand on Resident 11's genitals and Resident 10 was rubbing aggressively. Staff 8 stated Resident 10 saw her and stopped. Staff 8 separated the two residents and notified Staff 6 immediately. On 8/30/24 at 4:45 PM, Staff 1 (Administrator) acknowledged Resident 11 had been sexually abused and will continue to monitor the resident for any psychological impact.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 2 of 4 halls (East and Annex Halls), 1 of 1 dining room, and 2 of 4 sampled residents (#s 28 and 37) reviewed for dining and skin conditions. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. The Centers for Disease Control and Prevention website, section titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers, when shared. Using a [glucometer] for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). [Glucometers] should be cleaned and disinfected after every use. The facility's 4/2019 Disinfection of Point-of-Care Devices/Instrument Policy & Procedure specified all point-of-care devices, including glucometers, will be cleaned and disinfected according to manufacturer recommendation using EPA (Environmental Protection Agency) approved disinfectants. Resident 37 was admitted to the facility in 7/2023 with diagnoses including type II diabetes. Resident 28 was admitted to the facility in 8/2023 with diagnoses including type II diabetes. On 8/14/24 at 12:29 PM Staff 32 (Agency RN) was observed in Resident 28 and 37's shared room. Staff 32 used a glucometer and obtained Resident 28's blood sugar. Staff 32 returned to the medication cart in the hallway, placed the glucometer on the top surface of the cart and disinfected the glucometer with an alcohol prep pad. At 12:35 PM Staff 32 returned to the room with the used glucometer and stated she was going to obtain Resident 37's blood sugar. The State Surveyor requested to speak with Staff 32 prior to obtaining Resident 37's blood sugar. Staff 32 stated she used alcohol wipes to disinfect shared glucometers because the purple top wipes caused a lot of errors and she had seen other nurses use them at the facility. On 8/14/24 at 12:40 PM Staff 6 (Infection Preventionist) stated she was unsure if alcohol wipes were effective against blood borne pathogens. On 8/14/24 at 1:05 PM Staff 6 provided the glucometer's manufacturer instructions which indicated the glucometer was to be disinfected between patient uses by wiping it with a CaviWipe towelette (durable towelettes that offer quick, easy-to-use, time-saving convenience and kill organisms in only three minutes) or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. Review of Resident 28 and Resident 37's health record revealed no diagnoses including viral bloodborne pathogens. On 8/14/24 at 2:33 PM Staff 2 (DNS) stated glucometers were to be disinfected according to manufacturer instructions and alcohol wipes were not to be used to disinfect glucometers as they did not kill blood borne pathogens. 2. The facility's 7/2024 Transmission Based Precautions Policy & Procedure specified the following related to Enhanced Barrier Precautions (EBP): -Residents with wounds required EBP. -Personnel was to wear gloves and a gown when dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, therapy and device care/use for a resident on EBP. -EBP applies when a wound is open and/or draining. Resident 28 was admitted to the facility in 8/2023 with diagnoses including heart failure, diabetes with a foot ulcer, cellulitis (a bacterial skin infection) of the left lower limb and acquired absence of the right foot. Resident 28's 5/20/24 Quarterly MDS revealed the resident was cognitively intact, had a total of two venous ulcers (leg ulcers caused by problems with blood flow in a person's leg veins) and arterial ulcers (a painful, deep sore or wound in the skin of the lower leg or foot) and received the application of nonsurgical dressings and ointments/medications other than to her/his feet. On 8/12/24 at 10:20 AM Staff 24 was observed to push Resident 28 in her/his wheelchair from the facility's shower room, down the hall and into the resident's shared room. The resident's legs were not covered and revealed large open wounds with chunks of missing skin and yellowish puss on both legs. A sign outside of Resident 28's room indicated she/he was on EBP. After Staff 24 assisted the resident to her/his side of the room, Staff 24 placed a towel under the resident's left foot and right stump, removed the resident's breakfast tray and exited the room. Staff 24 did not wear gloves or a gown when she pushed the resident in her/his wheelchair or when she placed a towel under her/his foot/stump. Staff 24 was not observed to perform hand hygiene after she pushed the resident in her/his wheelchair and prior to retrieving the towel that was placed under her/his bare foot/stump. At 10:23 AM Resident 28 was observed with her/his bare foot/stump off of the towel and directly on the floor. At this time, the resident's right leg was observed with blood running down. On 8/12/24 at 10:32 AM Staff 24 stated staff were supposed to wear gloves, a mask and a gown whenever they worked with residents who were on EBP. Staff 24 stated Resident 28 was on EBP and she did not wear the appropriate PPE when she transported the resident from the shower room or when providing her/him with a towel. Staff 24 further stated she liked to put a towel under the resident's foot/stump because they leaked water. Observations of Resident 28 on 8/12/24 from 10:23 AM to 10:59 AM revealed Resident 28's foot/stump to rest uncovered on the floor of her/his room. A pool of clear fluid was observed on the ground where the resident's foot/stump had previously rested. At 10:43 AM Staff 15 (RN) entered the resident's room, asked the resident if the towel was underneath her/his foot/stump, said oh, pointed to the towel on the ground and left the room. On 8/12/24 at 10:59 AM Staff 15 re-entered the resident's room to provide treatments to both of the resident's legs. Prior to completing the treatments, Staff 15 was observed to step in the pool of clear fluid on the floor of the resident's room. At 11:47 AM Staff 15 stated she expected staff to wear gloves when they assisted Resident 28 when her/his wounds were uncovered. Staff 15 stated she thought the resident's foot and stump should be on a towel when uncovered because they wept a lot and I don't know what else to do. On 8/13/24 at 12:45 PM Resident 28 was observed to sit in her/his wheelchair in her/his room. The resident's leg wounds were covered and she/he wore non-skid socks over the bandages on her/his feet. No towel was observed underneath the resident's foot/stump and a wet towel was observed in a clump next to the foot of the resident's bed. Resident 28 stated her/his foot and stump were always leaking but she/he could not tell or feel it when they did. On 8/14/24 at 9:40 AM Staff 10 (CNA) stated she had frequently seen a trail of liquid coming from Resident 28's feet on the floor throughout the facility. Staff 10 stated she had not been instructed on what to do when she noticed the trail of liquid on the floor from the resident's feet but thought housekeeping regularly mopped the floors. Staff 10 further stated she regularly changed the resident's socks and towel as they were often soaked all the way through with liquid from her/his feet. On 8/14/24 at 10:21 AM Staff 29 (CNA) stated she had noticed a couple of times in the hallway liquid trails coming from Resident 28's feet. Staff 29 stated she noticed some staff just put a towel down when they noticed the trail but she would clean it up with a towel and then take the dirty towel to the laundry. On 8/14/24 at 11:53 AM Resident 28 was observed to wheel her/himself down the hall, around a corner and into a shared resident bathroom. A trail of clear liquid was observed on the ground that followed the resident from her/his room to the bathroom. An unidentified staff person assisted the resident into the bathroom, closed the door behind the resident and stepped into the liquid left on the floor. From 11:53 AM to 12:15 PM five different staff and two different residents were observed to step in the liquid Resident 28 left behind on the floor. On 8/14/24 at 2:54 PM Resident 28 stated her/his room was cleaned and mopped only once in the morning each day. On 8/15/24 at 9:38 AM Staff 29 was observed to leave the resident shower room with a black garbage bag filled with used towels. Staff 29 did not wear gloves or a gown. At 9:39 AM Staff 29 stated she just gave Resident 28 a shower during which she wore gloves and a mask but not a gown. Staff 29 stated the garbage bag was filled with dirty towels from Resident 28's shower. On 8/15/24 at 11:50 AM Staff 6 (Infection Preventionist) and Staff 17 (RN Consultant) acknowledged the findings of this investigation. Staff 17 stated she expected staff to wear a gown and gloves when with Resident 28 any time her/his wounds were not covered and when assisting her/him with a shower. Staff 17 stated she expected Resident 28's wounds to be covered when out of her/his room and staff should clean the floor as soon as possible if the liquid coming from Resident 28's foot/stump could not be contained. Staff 17 further stated she expected staff to keep on top of changing the resident's dressings and socks. 41458 3. The facility's Hand Hygiene Policy, last revised 12/15/21, indicated hand hygiene was the primary means of preventing the transmission of infection. On 8/12/24 between the hours of 12:11 PM and 12:30 PM, during the lunch meal in the main dining room and residents' lunch tray pass on the Annex Hall, the following observations were made: -12:18 PM Staff 26 (CNA) was observed in the main dining area wearing a surgical mask which was below her nose. Staff 26 adjusted her surgical mask and then assisted a resident to prepare and set-up their lunch tray. No hand hygiene was performed. Staff 26 was, again, observed with her surgical mask below her nose, adjusted her mask and then assisted another resident to prepare and set-up their tray, touching the resident's silverware and tray items. No hand hygiene was completed after adjusting her mask or between assisting residents. -12:25 PM Staff 27 (CNA) was observed passing beverages on Annex Hall. Staff 27 entered room [ROOM NUMBER], adjusted the resident's bedside table and moved objects on the table prior to placing the beverage down. Staff 27 was observed repeating this process for residents' in rooms 113, 114, 116 and 119. Staff 27 did not complete hand hygiene after exiting or before entering any of the residents' rooms. On 8/12/24 at 12:22 PM Staff 26 stated she was not supposed to touch her surgical mask but if she did, she was supposed to complete hand hygiene. Staff 26 confirmed she did not complete hand hygiene after touching her mask or between residents. On 8/12/24 at 12:31 PM Staff 27 stated he was supposed to complete hand hygiene after touching something belonging to a resident. Staff 27 stated he tried to do as much hand hygiene as possible but did not always consistently perform hand hyiene. On 8/16/24 at 8:35 AM and 10:01 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Interim DNS) stated staff were expected to complete hand hygiene each time they went in and out of a resident's room. Staff 1 and Staff 2 stated they also expected hand hygiene to be completed after touching something dirty and before touching something clean. 47001 4. On 8/13/24 at 12:56 PM Staff 13 (CNA) was observed in the east hall picking up dirty food trays. Staff 13 picked up room [ROOM NUMBER]'s dirty tray, placed it in the cart and went into room [ROOM NUMBER], no hand hygiene was completed. Staff 13 exited room [ROOM NUMBER] and went into room [ROOM NUMBER], no hand hygiene was completed. Staff 13 exited room [ROOM NUMBER] with a dirty food tray, placed it in the cart and with into room [ROOM NUMBER], no hand hygiene was completed. Staff 13 was observed in room [ROOM NUMBER] attempting to assist the resident with eating, the resident refused the meal, staff 13 exited room [ROOM NUMBER] with the dirty food tray and placed it in the cart, no hand hygiene was completed. Staff 13 stated she was not taught to clean her hands between picking up dirty food trays. On 8/16/24 at 8:35 AM Staff 3 (Interim DON) stated staff are expected to perform hand hygeine each time they go in and out of rooms.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 3 of 4 halls reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 8/12/24 through 8/16/24 identified the following issues: -A light cover on the annex hall near room [ROOM NUMBER] was cracked with missing chunks of the lighting cover. -One hall light was out on the annex hall near room [ROOM NUMBER]. -Two lights were out in the dining room. -Dirty vent covers in rooms 155, 157, 158, the center hall outside the employee room and outside the RCM office near the west hall. -The east hall near the O2 storage closet had a torn/jagged baseboard to the left of the closet door. -The east hall near the emergency exit had broken pieces of plastic on both wall corners approximately 3 inches in length that were sharp/jagged. -A lower corner wall near the west hall and RCM office was separated with approximately 3 inches of separation with sharp/jagged edges. -A lower corner wall near the center hall and resident bathroom had approximately 6 inches of missing/broken plastic with sharp/jagged edges. -The entrance to the clean laundry area had a wall corner with broken sharp/jagged edges in three different areas on the wall protector. -The entrance to the facility where the directory sign was had a corner with approximately 3-4 inches of missing plastic protector with sharp/jagged edges. -The west hall outside the nurses station had a wall corner with approximately 3-4 inches of missing plastic protector with sharp/jagged edges. On 8/16/24 at 10:24 AM Staff 1 (Administrator) and Staff 18 (Maintenance Director) acknowledged the identified concerns.

Based on interview and record review it was determined the facility failed to involve residents/representatives in the care planning process for 2 of 2 sampled residents (#s 4 and 41) reviewed for care planning and dementia. This placed residents at risk for unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 5/2009 with diagnoses including dementia. A review of Resident 4's medical record revealed the last care conference completed for Resident 4 was on 2/5/24. On 8/15/24 at 10:12 AM Staff 11 (SSD) stated Resident 4 had not had a care conference completed since 2/5/24. On 8/15/24 at 12:54 AM Staff 6 (LPN Resident Care Manager) and Staff 4 (LPN Resident Care Manager) stated care plan revisions and reviews are reviewed with the resident and/or representatives on a quarterly basis during the care conference. Staff 6 stated Resident 4 was overdue for a care conference. 2. Resident 41 was admitted to the facility in 1/2023 with diagnoses including acute respiratory failure. A 6/15/24 Quarterly MDS revealed Resident 41 had moderate cognitive decline. A review of Resident 41's medical record revealed the last care conference completed for Resident 41 was on 1/24/24. On 8/14/24 at 11:22 AM Staff 4 (LPN Resident Care Manager) stated Resident 41 had a care conference completed in June 2024, she was unsure of the date, she was unsure if the resident's representative was invited and she was unable to provide documentation of the care conference being completed in June 2024. On 8/14/24 at 11:48 AM Staff 11 (SSD) stated the last care conference documented for Resident 41 was in 1/2024. Staff 11 stated she was getting caught up and back on track with care conferences. On 8/15/24 at 12:54 PM Staff 4 and Staff 6 (LPN Resident Care Manager) stated care plan revisions and reviews are reviewed with the resident and/or representatives on a quarterly basis during the care conference.

Based on interview and record review it was determined the facility failed to follow up on grievances for 1 of 1 resident (#309) reviewed for personal property. This placed residents at risk for unmet needs. Findings include: Resident 309 was admitted to the facility in 6/2020 with diagnoses including depression. On 7/8/24 a public complaint was received with allegations of missing personal property. On 8/12/24 at 5:25 PM Witness 1 (Complainant) stated Resident 309 was discharged from the facility in 4/2024 and was missing some personal belongings. Witness 1 stated she informed the facility via phone of the missing items but had not received a reply from the facility. On 8/13/24 at 9:41 AM Staff 4 (SSD) stated she never received a complaint or grievance related to missing personal items from Resident 309 or her/his representatives. An 8/14/24 review of the facility grievance binder revealed no evidence of a grievance from Resident 309 or her/his representatives. On 8/14/24 at 11:20 AM Staff 4 (LPN Resident Care Manager) stated she was Resident 309's care manager but had not received any grievances or complaints from Resident 309 or her/his representatives related to missing personal items. On 8/15/24 at 10:42 AM Staff 12 (Receptionist) stated she received a call from Witness 1 after Resident 309 discharged . Staff 12 stated Witness 1 reported not all of Resident 309's personal items had transferred with her/him upon discharge. Staff 12 stated she could not remember if she reported this to management. On 8/15/24 at 11:29 AM Staff 1 (Administrator) stated he had not received a report of Resident 309 missing any personal items. On 8/16/24 at 8:15 AM Staff 11 stated she was the facility grievance officer. Staff 11 stated she expected staff to report all written and verbal grievances to her or the administrator. On 8/16/24 at 8:25 AM Staff 1 stated verbal grievances are expected to be treated and followed up on just like written grievances.

Based on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalization s for 1 of 1 sampled resident (# 56) reviewed for hospitalization . This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: Resident 56 was admitted to the facility in 5/2024 with diagnoses including urinary tract infection and bacteremia (bacteria in blood). Resident 56's 5/23/24 Discharge MDS indicated the resident was discharged to an acute care hospital. A review of Resident 56's health record revealed no documentation to indicate the state/local Ombudsman was notified Resident 56 was discharged to a hospital. On 8/15/24 at 12:51 PM Staff 1 (Administrator) stated the facility did not notify the Ombudsman of discharged residents.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 2 of 3 residents (#s 4 and 56 ) reviewed for hospitalization . This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 4 was admitted to the facility in 5/2009 with diagnoses including epilepsy and dementia. A 1/31/24 Progress Note revealed Resident 4 experienced a change in condition which required increased medical attention and she/he was transferred to a hospital. A review of Resident 4's health record revealed no documentation to indicate a copy of the facility's bed hold policy was provided to Resident 4 when she/he experienced a change in condition and was transferred to a hospital. On 8/15/24 at 1:24 PM Staff 1 (Administrator) confirmed a bed hold policy was not provided to Resident 4 when she/he experienced a change in condition and was required to be transferred to a hospital. On 8/16/24 at 8:52 AM Staff 3 (Interim DNS) confirmed a bed hold policy was not provided to Resident 4 when she/he was transferred to a hospital. 2. Resident 56 was admitted to the facility in 5/2024 with diagnoses including urinary tract infection and bacteremia (bacteria in blood). A 5/23/24 Progress Note revealed Resident 56 experienced a change in condition which required increased medical attention and she/he was transferred to a hospital. A review of Resident 56's health record revealed no documentation to indicate a copy of the facility's bed hold policy was provided to Resident 56 when she/he experienced a change in condition and was transferred to a hospital. On 8/15/24 at 1:24 PM Staff 1 (Administrator) confirmed a bed hold policy was not provided to Resident 56 when she/he experienced a change in condition and was required to be transferred to a hospital. On 8/16/24 at 8:52 AM Staff 3 (Interim DNS) confirmed a bed hold policy was not provided to Resident 56 when she/he was transferred to a hospital.

Based on observation, interview and record review it was determined the facility failed to accurately assess residents for oxygen therapy and wounds for 2 of 6 sampled residents (#s 22 and 37) reviewed for respiratory care and skin conditions. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Resident 22 was admitted to the facility in 1/2023 with diagnoses including heart attack and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe). Resident 22's 12/17/24 through 6/11/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 LPM (liters per minute) per NC (nasal cannula-a non-invasive medical device that provides supplemental oxygen to resident's through their noses) for signs of cyanosis (bluish or purple discoloration of the skin, lips and nail beds caused by lack of oxygen), symptoms of dyspnea (difficulty breathing) or shortness of breath. Resident 22's 6/11/24 through 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 3 LPM to 5 LPM as needed per NC. Resident 22's 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 LPM to 4 LPM continuously per NC. Resident 22's 6/12/24, 7/3/24 and 8/6/24 Significant Change MDSs indicated Resident 22 did not require supplemental oxygen therapy. Multiple observations from 8/12/24 through 8/16/24 between the hours of 8:00 AM and 3:30 PM revealed Resident 22 received supplemental oxygen therapy. On 8/15/24 at 11:35 AM Staff 4 (RNCM) confirmed Resident 22 received supplemental oxygen therapy and the resident's MDSs should have reflected the resident's need for oxygen. 47000 2. Resident 37 was readmitted to the facility in 2/2024 with diagnoses including diabetes, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and an acquired absence of right toes. Resident 37's 5/10/24 and 5/17/24 Podiatry Outpatient Notes indicated the resident had a diabetic foot ulcer. Resident 37's 7/14/24 Quarterly MDS indicated the resident had a surgical wound and she/he did not have a diabetic foot ulcer. On 8/16/24 at 11:46 AM Staff 2 (DNS) and Staff 3 (Interim DNS) acknowledged the findings of this investigation and Staff 3 confirmed Resident 37's MDS was inaccurate.

Based on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 2 of 7 sampled residents (#s 22 and 28) reviewed for respiratory care and unnecessary medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 22 was admitted to the facility in 1/2023 with diagnoses including heart attack and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe). Resident 22's 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 to 4 LPM (liters per minute) continuously per NC (nasal cannula-a non-invasive medical device that provides supplemental oxygen through the nose). Resident 22's 5/14/24 (most current) Care Plan indicated the resident was to receive oxygen per NC at 2 LPM as needed to maintain oxygen saturation levels (a measurement of how well the lungs are working) between 88% and 92%. Observations from 8/12/24 through 8/16/24 between the hours of 8:00 AM to 3:30 PM revealed Resident 22 received oxygen therapy at 3 LPM, continuously. On 8/14/24 at 2:49 PM Staff 21 (RN) stated Resident 22 received continuous oxygen per NC. On 8/15/24 at 12:48 PM Staff 3 (Interim DNS) reviewed Resident 22's oxygen orders and current care plan. Staff 3 stated Resident 22's care plan did not reflect the resident's current supplemental oxygen orders and she expected the resident's care plan and oxygen orders to match. 47000 2. Resident 28 was admitted to the facility in 8/2023 with diagnoses including heart failure. Resident 28's 5/31/24 Nutrition At Risk Care Plan indicated the resident was to be weighed weekly. Resident 28's 8/2024 Physician Orders directed the resident to be weighed daily. On 8/15/24 at 9:39 AM Staff 29 (CNA) stated she was unsure if Resident 28 was to be weighed weekly or daily but stated she found this information in the resident's care plan. On 8/15/24 at 12:14 PM Staff 3 (Interim DNS) reviewed Resident 28's Physician Orders, stated she/he was to be weighed daily and confirmed the care plan needed to be revised.

Based on interview and record review it was determined the facility failed to implement policies and procedures for the prevention of sexual abuse for 2 of 2 sampled residents (#s 1 and 2) reviewed for abuse. This failure, determined to be an immediate jeopardy situation, placed residents at risk for sexual abuse when staff witnessed repeated nonconsensual sexual activity without putting interventions in place. Findings include: A 1/2023 facility abuse policy indicated the following. - A thorough investigation is completed through a systematic collection and review of evidence/information that describes and explains an event or series of events. It seeks to determine if abuse occurred, and how to prevent further occurrences. - Sexual abuse is defined as sexual contact where the resident has no ability to consent. - Residents with sexual behaviors are assessed to determine their ability to give informed consent related to sexual acts. - Staff with knowledge of inappropriate sexual comments or contact between residents are to report immediately to the facility administration. Resident 1 was admitted in 12/2022 with diagnoses including schizoaffective disorder, bipolar disorder and cognitive impairment. Resident 1's 1/12/24 Quarterly MDS indicated moderate cognitive impairment. Resident 2 was admitted in 4/2023 with a diagnosis of cognitive impairment. Resident 2's 1/19/24 Quarterly MDS indicated moderate cognitive impairment. A Facility Reported Incident (FRI) was submitted on 1/29/24 which indicated Resident 1 was observed fell ating Resident 2 on 1/27/24. Staff 3 (CNA) separated the two residents and informed management. A Review of Resident 1 and 2's clinical records from 1/1/24 through 1/27/24 revealed the following regarding their sexual interactions: - No progress notes. - No physician orders. - No monitoring tasks for CNAs. - No care plan revisions for Resident 1. - No sexual behavior care plan for Resident 2. - No notification of Resident 2's public guardian. - No notification of either physician. - No facility sexual consent assessment. - An untitled document dated 1/15/24, written by Witness 1 (Licensed Clinical Social Worker, LCSW), which indicated a sexual incident between Resident 1 and Resident 2 occurred a few days prior. The document indicated Resident 1 did not have the cognitive capacity to understand the consequences of engaging in a sexual relationship. Witness 1 recommended moving either resident's room to a different room to monitor Resident 1's safety as Resident 1 was at risk for sexual abuse. On 1/30/24 at 10:45 AM Staff 1 (Administrator) and Staff 2 (DNS) stated on 1/29/24 the facility put interventions in place to prevent sex abuse. The facility initiated one on one supervision of Resident 1. The ombudsman, police, providers, and responsible parties were notified. Resident 1 was moved to the other side of the facility. Staff 2 requested a psychological review of both residents. In-services were initiated for all staff related to identification and reporting of abuse. On 1/30/24 at 11:48 AM Staff 3 (CNA) confirmed she observed Resident 1 and Resident 2 engaging in a sex act in the doorway of Resident 2's room on 1/27/24. Staff 3 stated she reported the incident to Staff 4 (LPN). Staff 3 stated the incident was reported to Staff 5 (HR/Payroll) the manager of the day on 1/27/24. Staff 3 indicated she was told by management that because both residents were cognitively impaired there was no problem with the behavior. Staff 3 confirmed she only reported the incident because it occurred within eyesight of other residents. On 1/30/24 at 1:23 PM Staff 5 stated, on 1/27/24 when she was manager of the day, Staff 4 came to her and said I don't know what to do, [Resident 1] and [Resident 2] were doing something. Staff 5 stated she told Staff 4, If the residents were doing something to make sure neither of them were doing anything they didn't want to. If one doesn't want to then separate them. When asked to clarify what was meant by doing something, Staff 5 indicated she was not sure what occurred. Staff 5 stated she did not know Resident 1 and Resident 2 were involved in an actual sex act and told Staff 4 she should have been notified sooner. Staff 5 stated she never followed up with Staff 4 regarding this incident. Staff 5 stated she would have had to ask what the proper procedure was. On 2/1/24 at 4:00 PM Witness 1 stated her understanding at the time of the 1/15/24 evaluation was that a sex act occurred. Witness 1 stated she shared her recommendations with facility administration and asked repeatedly from 1/15/24 through 1/29/24 if the residents were moved for Resident 1's safety. On 2/1/24 at 10:51 AM Staff 7 (CNA) indicated she observed Residents1 and Resident 2 engage in a sexual activity during a bible study activity during the week of 1/22/24. Staff 7 stated she saw Resident 1 holding Resident 2's exposed genitalia. Staff 7 stated management was made aware of the incident and as a result staff were told to try to keep the residents apart. Staff 7 stated keeping the residents separated was very difficult because Resident 1 and Resident 2's rooms were right across from each other. Staff 7 stated she was aware of sexual activity between Residents 1 and 2 since approximately 1/11/24. On 2/1/24 at 11:38 AM Staff 8 (CNA) indicated she was made aware of Resident 1 and Resident 2's sexual activities by fell ow staff but received no instruction from management on how to keep the residents safe. Staff 8 stated the attempts to keep Residents 1 and 2 separate were constant the last week and a half. Staff 8 stated staff did not have an updated plan of care regarding the residents' sexual activity, and as a result did not know to keep Residents 1 and 2 separated. On 2/1/24 at 12:07 PM Staff 9 (LPN) stated it was difficult to pinpoint when Resident 1 and Resident 2's sexual activities started because the facility staff did not react when they became aware of the incidents. Staff 9 stated she expected an investigation of the residents' relationship would have occurred, and interventions put in place. Staff 9 estimated the residents' sexual activities started on approximately 1/1/24. During interviews on 1/30/24 at 12:40 PM, 2/1/24 at 12:43 PM, and 2/2/24 at 9:38 AM Staff 6 (Social Services Director) stated 1/27/24 was the first time anything was reported to me. Staff 6 stated until something is written down and documented I do not respond. Staff 6 confirmed she heard talk of Resident 1 and 2 having a sexual relationship prior to 1/27/24 but did not investigate it. Staff 6 stated she was aware of the evaluation completed and was aware of the recommendation to separate Residents 1 and 2 for their safety. Staff 6 confirmed Resident 2 was moved on 1/29/24, 14 days after it was recommended the residents be separated for Resident 1's safety, and two days after the 1/27/29 incident. Staff 6 confirmed the residents' sexual interactions should have been documented from the beginning. Staff 6 confirmed no action was taken regarding the 1/27/29 sexual incident between Residents 1 and 2 until 1/29/24. On 2/1/24 at 1:20 PM Staff 10 (RN) stated staff were not trained properly in what to do when they observed a sex act between two residents. Staff 10 confirmed there was no documentation that Residents 1 and 2 were monitored for sexual behavior. On 1/30/24 at 10:24 AM time Staff 2 acknowledged Witness 1's recommendations for Resident 1's safety were not followed. Staff 2 indicated in response to the sexual activity between Residents 1 and 2 the facility should have put immediate safety interventions in place, requested a psychiatric consult for both residents, notified all needed parties, and updated care plans. Staff 2 indicated staff who were aware of the sexual activities should have separated the residents and informed management, and management should have initiated an investigation when the first incident occurred. Staff 2 confirmed these activities were not initiated until 1/29/24, two days after the date of the most recent incident. On 2/2/24 at 2:39 PM the facility was notified of the Immediate jeopardy (IJ) situation, determined to begin as of 1/15/24, and an immediacy removal plan was requested. On 12/2/24 at 4:20 PM the facility submitted an acceptable immediacy removal plan. The immediacy removal plan included the following: Residents 1 and 2 still reside in the facility. Resident 1 was assessed for s/sx of psychological distress and has been placed on 1:1 staff supervision. Resident 2 was assessed for s/sx of psychological distress. Completed on 1/31/24. Residents 1 and 2's care plans have been updated to reflect the current plan of care, including sexual consent capacity assessments. Resident 2 has been educated on safe sex practices and sexual consent facility policy. Completed on 1/30/24. Residents who reside in the facility are at potential risk for this deficient practice. Resident and staff interviews to be completed to determine if there have been any other sexual relationships identified. Completed 2/2/24 by 4:00pm. 1. The alleged perpetrator was interviewed regarding the behavior and placed on 1:1 supervision. Completed on 1/29/24. Resident placed on alert monitoring for any continued behaviors. Completed 1/29/24. Complete sexual consent capacity assessment 1 and 2. Completed on 1/31/24. 2. Alleged victim interviewed regarding the incident and assessed for any emotional distress due to the interaction.Completed 1/29/24. Resident placed on alert monitoring for any distress related to the incident. Completed on 1/29/24. Complete a sexual consent capacity assessment for resident 1 and 2. Completed on 1/31/24. 3. Providers of the involved residents notified. Completed 1/29/24. 4. Families/POA of the involved residents notified. Completed on 1/30/24. 5. Local police notified. Completed 1/29/24. 6. Ombudsman notified. Completed on 1/29/24. 7. Pharmacy consultant notified to complete medication review on alleged perpetrator. Completed on 1/31/24. 8. Interview able residents questioned regarding their interactions with other residents to help identify any other potential residents the female resident may have performed sexual acts on. Completed 1/30/24. If other residents are identified, the center will complete steps 2 through 7 for them. Completed 1/30/24. 9. Non-interview able residents had their skin assessments completed to identify any potential impairments to their groin area indicating sexual contact. Completed on 1/31/24. If other residents are identified, center will complete steps 2 through 7 for them. Completed on 1/31/24. 10. Staff interviews initiated to help identify any other instances where the resident may have been engaged in sexual activity with another resident. Completed on 2/1/24. For any additional instances identified, the center will follow steps 2 through 7. Completed on 2/1/24. 11. Current actively working Staff have been re-educated on center abuse and neglect policy on 2/2/24 by 5:00pm. All Staff have been notified that they need to be reeducated prior to the start of shift. Resident council held to review resident rights with those in attendance, completed on 2/1/24. 12. Resident care plan reviewed and updated on 1/31/24. 13. An ad hoc QAPI meeting held with the medical director and members of the IDT to review incident and active plan to prevent abuse in the center. Feedback from the medical director solicited for any recommended additions to the current interventions. Completed on 1/30/24. - Administrator and/or designee-initiated re-education with staff on what to do if they see residents engaging in sexual acts with other residents, who to alert, and how to protect the residents from non-consensual sex. Education was initiated on the facility's abuse and neglect policy, and sexual consent policy. Completed on 2/2/24. - Record reviews on Resident 1 and Resident 2 were completed to look for any other incidents to investigate. Completed on 2/1/24. - QAPI meeting and medical director in agreement with IDT. Social Services involved in assessment process along with medical director. Completed on 1/31/24. - To ensure ongoing compliance, DNS or designee will conduct chart review, resident and staff interviews around sexual activities weekly x 4, then monthly x 2, and will continue until compliance is achieved. Results of audits will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. - The Administrator is responsible for compliance. - Dates when the corrective action will be completed: 2/2/24. The immediacy was determined to be removed on 2/2/24 at the close of business based on onsite verification of implementation of the IJ removal plan.

Based on interview and record review it was determined the facility failed to ensure a resident was provided supervision and positioning assistance with eating and follow a resident's care plan related to bed mobility and bathing for 2 of 3 sampled residents (#s 5 and 11) reviewed for accidents. This resulted in Resident 5 aspirating while eating without supervision and positioning assistance. Findings include: 1. Resident 5 was admitted to the facility in 2023 with diagnoses including difficulty swallowing following a stroke and respiratory failure. Resident 5's Care Plan initiated on 7/11/23 indicated the resident required one-on-one staff supervision while eating. A Progress Note dated 7/23/23 indicated Resident 5's breakfast tray was left at the resident's bedside without the head of the bed elevated. The resident ate breakfast without staff assistance, began coughing and displayed signs and symptoms of aspiration (when food enters the lungs or airway by accident). The nurse assisted the resident with deep breathing and appeared to clear the obstruction. The resident's lung sounds were diminished with wheezing. A facility incident investigation dated 7/23/23 indicated a morning meal tray was left at the resident's bedside and the resident started eating without the head of the bed raised. The resident was coughing significantly and had signs and symptoms of aspiration. The report indicated Neglect not substantiated. A chest x-ray dated 7/23/23 indicated Resident 5 had basal infiltrate (substance denser than air in an area of the lungs which should normally be clear) and small left-sided pleaural effusion (fluid between the two linings of the lung cavity) possibly due to aspiration. Resident 5's 7/24/23 Cognitive Loss / Dementia, Nutritional Status and ADL Functional / Rehabilitation Potential CAAs indicated the resident had some impaired cognition related to a recent stroke. The resident had impaired swallowing and required altered food texture including thickened fluids due to a recent stroke. The resident required extensive assistance with most ADLs. On 12/21/23 at 10:25 AM Staff 8 (CNA) stated on the morning of 7/23/23 she was assigned to answer call lights while other staff were passing meal trays to residents in their rooms. She stated she told the staff passing trays Resident 5 needed staff assistance with eating. Staff 8 did not know who left the tray at Resident 5's bedside unsupervised. On 12/21/23 at 1:22 PM Staff 9 (CNA) stated she may have left the tray at Resident 5's bedside and she did not know the resident required supervision with eating. Staff 9 stated the resident's care plan indicated she/he only needed to have the tray set up for her/him. On 12/21/23 at 12:06 PM Staff 10 (Regional Director of Operations) and Staff 1 (Administrator) confirmed Resident 5's care plan was not followed and their internal investigation should have substantiated neglect. 2. Resident 11 was admitted to the facility in 2023 with diagnoses including right knee fracture and obesity. a. Resident 11's Care Plan initiated on 7/3/23 indicated the resident required the extensive assistance of two people with bathing, bed mobility and toileting. The resident required a mechanical lift and the extensive assistance of two people with transfers. A facility incident report dated 8/9/23 indicated Resident 11 fell in the shower while being assisted by Staff 6 (CNA). The resident's care plan was not followed because the resident was non-weight bearing on the right leg and used a mechanical lift for transfers. On 1/4/24 at 9:10 AM Staff 6 stated Resident 11 started to sit on the shower chair but missed the edge and slid to the floor. Staff 6 acknowledged he was the only staff assisting the resident with the shower at the time of the fall and stated he was not aware the resident was non-weight bearing. On 1/4/24 at 9:58 AM Staff 1 (Administrator) confirmed Resident 11's care plan was not followed which resulted in a fall. b. Resident 11's Care Plan initiated on 7/3/23 indicated the resident required the extensive assistance of two people with bathing, bed mobility and toileting. The resident required a mechanical lift and the extensive assistance of two people with transfers. A facility incident report dated 8/17/23 indicated Resident 11 fell out of her/his bed when Staff 7 (CNA) rolled the resident over too far while providing incontinence care. On 1/3/24 at 9:11 AM Staff 7 stated Resident 11 rolled over too far and her/his momentum took her/him off the bed. Staff 7 did not recall another staff assisting her and most staff provided care with just one staff because the resident was able to help. On 1/4/24 at 9:58 AM Staff 1 (Administrator) confirmed Resident 11's care plan was not followed which resulted in a fall.

Based on observation, interview and record review it was determined the facility failed to assess weight loss related to a unassessed downgraded diet for 1 of 5 sampled residents (#34) reviewed for nutrition. This resulted in Resident 34 experiencing a 39.7 pound weight loss after being placed on a downgraded diet, voiced dislike of the puree diet texture and had a decline in food intake. Findings include: Resident 34 was admitted in 5/2019 with [DIAGNOSES REDACTED]. Resident 34 was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. The 5/14/19 Medical Nutrition Therapy Admission Assessment indicated Resident 34 ate 76-100% of breakfast and dinner meals and 51-100% of lunch and was on a mechanical soft textured diet for ease of chewing. Resident 34 had no swallowing problems, stated her/his appetite was pretty good and was eating well. The 5/17/19 Admission MDS Assessment for Section K (Swallowing and Nutritional Status) indicated Resident 34 had no swallowing problems and was on a mechanically altered diet and for Section L (Dental Status) revealed the resident had no teeth. Food intake records reviewed from 6/1/19 through 7/18/19 revealed Resident 34 consumed 76-100% of intakes as follows: Prior to 6/28/19 diet change: -Breakfast 82% of the time; -Lunch 63% of the time; -Dinner 25% of the time and -Snacks 100% of the time. After 6/28/19 diet change to puree textures: -Breakfast 65% of the time; -Lunch 16% of the time; -Dinner 16% of the time and -Snacks 0% of the time. The 6/26/19 physician readmission orders [REDACTED] -Renal diet, CCHO (Consistent Carbohydrate), regular textures with one can, protein low carb. The 6/28/19 physician orders [REDACTED]. -Renal diet, CCHO, puree textures with 8 ounces Nova Source supplement at lunch meal. The 6/26/19 to 7/16/19 weight records were reviewed and indicated the following: -6/26/19 readmission weight: 260 pounds -7/9/19 weight: 224.5 pounds and -7/16/19 weight 220.3 pounds. There was no evidence noted in Resident 34's records the facility had completed a re-weigh on 6/26/19. From 6/26/19 to 7/16/19, Resident 34 lost 39.7 pounds which was a 15.6% weight loss. The 6/28/19 Nursing Progress notes indicated the Director of Therapy Services found the resident choking while she/he was eating and Resident 34's diet was downgraded to puree textures. The 6/28/19 Medical Nutrition and Therapy Re-Assessment indicated Resident 34's diet was downgraded to puree textures. The report also indicated Resident 34's appetite was not good and the resident started eating smaller amounts at meals. Nutritional intervention included: adding 8 ounces of [MEDICATION NAME] daily at lunch, offering bedtime snacks and honoring food preferences. The nutritional goal was for wound healing. The 7/12/19 and 7/17/19 Dietitian Progress notes stated Resident 34 experienced a 13.7% weight loss from 6/26/19 to 7/9/19 and an additional 1.9% from 7/9/19 to 7/15/19. Resident 34 continued on a puree textured diet with supplements daily at lunch and had variable intake at meals. Resident 34 stated her/his appetite wasn't as good. The nutritional goal was for weight maintenance of lean body mass. There was no evidence Resident 34's downgraded diet and her/his dislike of the new diet was considered as a potential factor for weight loss. Multiple observations on 7/11/19 through 7/18/19 between the hours of 8:00 AM to 5:30 PM revealed Resident 34 received a puree textured diet. During an observation on 7/12/19 at 12:20 PM, Resident 34 stated she/he did not want puree foods because she/he did not like them. On 7/12/19 at 12:32 PM, Staff 20 (RNCM) stated Resident 34 was on a mechanical soft textured diet prior to her/his discharge to the hospital on [DATE] and had no difficulty tolerating the diet. The resident returned from the hospital with orders for a regular textured diet. On 6/28/19, the Director of Therapy walked by Resident 34's room and noted the resident coughing and downgraded the diet to puree textures. Staff 20 stated she expected Resident 34 would have had an SLP assessment to follow up on the change of diet, especially due to Resident 34 being a picky eater. She reported no orders were obtained due to a breakdown in requesting orders. She stated nursing could downgrade but not upgrade diets as this had to be done by the SLP. On 7/12/19 at 1:05 PM, Staff 36 (RD) stated at the end of 6/2019, Resident 34's diet was changed to puree textures and the resident reported a dislike of her/his puree textured diet. She reported it was a big change for Resident 34. She stated Resident 34 denied any swallowing problems and told the kitchen manager she/he did not like puree textures. She stated Resident 34 had an approximate 35 pound weight loss and a re-weigh had been requested. On 7/15/19 at 9:03 AM, Witness 10 (SLP) stated on 6/28/19 she walked by Resident 34's room and noticed the resident vomited something green. Witness 10 stated she thought maybe it had been medication and asked the resident if she/he choked and the resident stated no. Witness 10 stated she did not notice any choking or coughing but downgraded the diet. Witness 10 stated she was not informed Resident 34 lost weight and did not like puree textures. Witness 10 stated she did not receive an SLP order to assess diet textures to determine if this was an appropriate diet texture. On 7/17/19 at 2:42 PM, Staff 36 (RD) stated Resident 34's appetite had not been good since her/his diet was downgraded to puree textures. She stated she did not want to see Resident 34 losing that much muscle mass and did not want the resident's weight loss to continue trending downward. She stated it was not healthy to lose weight that rapidly and her goal was to stabilize Resident 34's weight. On 7/18/19 at 11:53 AM, Staff 2 (DNS) acknowledged Resident 34 had a significant weight loss, no follow up regarding the downgraded diet occurred and follow-up by the SLP to comprehensively assess Resident 34's diet should have been done.

Based on interview and record review it was determined the facility failed to ensure 1 of 4 sampled residents (#412) reviewed for medications was free from significant medication errors. This deficient practice resulted in Resident 412 missing 15 days of [MEDICATION NAME] acid [MEDICATION]). When the resident was restarted on [MEDICATION NAME] acid the resident had a [MEDICAL CONDITION] that lasted approximately five minutes and was hospitalized . Findings include: Resident 412 was admitted the facility in 7/2018, with [DIAGNOSES REDACTED]. The facility Incident Summary: Medication Error report revealed the following: -The order for [MEDICATION NAME] acid every eight hours ended 12/21/18; -The physician visited the resident on 12/17/18 and wrote a note to continue [MEDICATION NAME] acid indefinitely but no order was obtained; -On 12/21/18 the resident's [MEDICATION NAME] acid stopped; -On 1/6/19, during the pharmacist's review, it was noted [MEDICATION NAME] acid stopped and no replacement order was obtained; -On 1/6/19 the DNS re-activated the [MEDICATION NAME] acid order; -On 1/12/19 the resident had a [MEDICAL CONDITION] which lead to her/his hospitalization . The 12/2019 and 1/2019 Progress Notes revealed the following: -On 12/17/19 the physician wrote patient is on [MEDICATION NAME] acid for [MEDICAL CONDITION] orders from Veteran's Administration, considering patient has a history of [MEDICAL CONDITION], patient should continue medication indefinitely; -On 12/27/19 the physician noted current medications included [MEDICATION NAME] acid 250 mg/5 ml; -On 1/6/19 the order for [MEDICATION NAME] acid was updated; -On 1/12/19 the resident was on the toilet with uncontrollable body movement [MEDICATION NAME] approximately five minutes. Resident mumbled in native language, drooling and running nose. Left arm and left side of face appears limp. Licensed nurse called 911 .; -On 1/18/19 the resident readmitted to the facility The 12/2019 Physician order [REDACTED]. The 12/2018 and 1/2019 MAR indicated [REDACTED]. On 1/7/19 [MEDICATION NAME] acid 250 mg/5 mls, administer 500 mg every eight hours was restarted. There was no documented administration of [MEDICATION NAME] acid between 12/22/18 through 1/6/19. In an interview on 6/3/19 at 12:43 PM, Staff 11 (Medical Director) stated missing two weeks of [MEDICATION NAME] acid doses was a long time to be out of range for this medication. Staff 11 stated he was uncertain if restarting the medication would cause a [MEDICAL CONDITION]. In an interview on 6/4/19 at 9:46 AM, Witness 2 (Pharmacist) stated the resident was on a high dose of [MEDICATION NAME] acid and it should not have been stopped without titration down. Witness 2 stated stopping [MEDICATION NAME] acid for 15 days likely meant the resident had no [MEDICATION NAME] acid in his/her system and would need to restart at a lower dose and titrate to the appropriate amount through lab monitoring. Witness 2 stated restarting the resident on the same dose instead of starting at a lower dose and titration to the therapeutic level would shock a person's system, which can cause [MEDICAL CONDITION]. In an interview on 6/4/19 at 2:28 PM, Staff 1 (DNS) stated Staff 11 made the recommendation to have an open ended order for [MEDICATION NAME] acid but there was a miscommunication and the order was discontinued. Staff 1 stated when the order stopped in electronic system staff did not recognize the need to clarify the order before stopping [MEDICATION NAME] acid. Staff 1 stated she was notified of the missed medication during the pharmacist's review and the resident was restarted on the same dose of [MEDICATION NAME] acid and the resident had a [MEDICAL CONDITION].

Based on interview and record review it was determined the facility failed to ensure Witness 2 (Former Facility LPN) completed a thorough check for potential resident injuries before moving the resident and that Witness 3 (Former Facility CNA) followed the plan of care for bed mobility with incontinent care for 1 of 3 sampled residents (#1) reviewed for safety interventions. As a result Resident 1 sustained multiple fractures from an avoidable fall. Findings include: According to the Oregon State Board of Nursing standards of practice "Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER] (1) Standards related to the licensed nurse's responsibilities for client advocacy...(a) Advocates for the client's right to receive appropriate care...(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering..." "851-063-0090 Conduct Unbecoming a Nursing Assistant...(1) Conduct related to the client's safety and integrity...(e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured..." Resident 1 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 3/3/14 indicated the resident required extensive assistance of two persons for bed mobility. A facility investigation dated 4/8/14 indicated the resident experienced a fall on 4/8/14 at 1:30 pm from her/his bed. The resident was rolled in bed by Witness 3 (Former Facility CNA) without additional staff assistance. The resident rolled off the side of the bed and to the floor. The charge nurse, Witness 2 (Former Facility LPN) was summoned to the room. Witness 2 had staff Hoyer lift the resident back into bed before checking the resident for any potential injury. The investigation included a statement from Witness 3 which indicated she was aware the resident was care planned for two person assistance with bed mobility. Witness 3 stated she looked in the hall for other staff and did not see anyone handy. Witness 3 stated she did not go look for any other staff or ask any staff for assistance before moving the resident in bed. Witness 3 stated the nurse, Witness 2, checked the resident's hands, bent her/his knees and hips after the resident was transferred back to bed. The investigation included a witness statement from Staff 5 (CNA) which indicated she arrived to the room to assist the other staff to get the resident back in bed. The resident was placed on the sling for transfer. Witness 2 asked the resident if she/he had pain, the resident whimpered which grew louder when she/he was moved. When the resident's legs were moved to position the Hoyer lift the resident called out "my leg, my leg." The investigation included a statement from Witness 2 which indicated the resident's bed was raised approximately to the height of Witness 2's hip. The resident was face down on the floor and difficult to assess because of her/his location. There was bruising noted to the resident's knee and when moving the resident's right leg the resident stated "that really hurts, don't do that don't do that." In an interview on 5/27/14 at 11:13 am Witness 3 (Former Facility CNA) stated she did not review the care plan prior to moving the resident in bed, she was already aware the resident required two person assistance for bed mobility. She went to the hall but did not see any staff around. Witness 3 did not go look for staff or ask any staff to come help her. Witness 3 rolled the resident away from her with a draw sheet, the resident rolled off the bed and landed on the floor. According to Witness 3 the resident's bed was raised to a three or four foot height. Witness 3 stated the charge nurse, Witness 2, did not assess the resident until she/he was transferred back into bed. The resident was painful but that was not necessarily out of the resident's norm. In an interview on 5/27/14 at 10:20 am Witness 2 (Former Facility LPN) indicated she was called to the room because the resident was on the floor. Witness 2 "knew it was going to be bad because the CNAs change residents with the beds in the high position." When she got to the room the resident was face down on the floor and there was urine on the floor. Witness 2 got additional CNAs to help transfer the resident back to bed. Witness 2 stated she did not do a thorough check for injuries of the resident while on the ground. She thought it would be easier when in the bed. Witness 2 stated the resident had a bruise to the knee and complaints of leg pain. The resident had chronic leg pain prior to the fall. Witness 2 could not say why she didn't do more before the resident was moved. Refer to F-323

Based on interview and record review it was determined Witness 3 (Former Facility CNA) failed to ensure the required number of staff were utilized for bed mobility as care planned for 1 of 3 sampled residents (#1) reviewed for safety interventions. As a result Resident 1 sustained multiple fractures from a fall. Findings include: Resident 1 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 3/3/14 indicated the resident required extensive assistance of two persons for bed mobility. A facility investigation dated 4/8/14 indicated the resident experienced a fall on 4/8/14 from her/his bed. The resident was rolled in bed by Witness 3 (Former Facility CNA) without additional staff assistance. The resident rolled off the side of the bed and to the floor. The resident was sent to the hospital for evaluation and was found to have multiple fractures. The resident did not return to the facility. Additional notes provided in the facility investigation indicated Staff 2 (DNS) discussed with Witness 3 how the incident occurred. Witness 3 stated she was on the door side of the bed and used the draw sheet to turn the resident towards the window. The resident's legs started to slip off the bed and the resident fell to the floor. Witness 3 "looked into the hall," "but not seeing anyone chose to proceed with care on her own." Hospital history and physical dated 4/8/14 indicated the resident sustained [REDACTED]. After X-rays were completed the resident was found to have two broken legs above the knee and a broken right hip. The resident additionally sustained a laceration above the right eye. In an interview on 5/27/14 at 11:13 am Witness 3 (Former Facility CNA) stated she did not review the care plan prior to moving the resident in bed. Witness 3 indicated she was already aware the resident required two person assistance for bed mobility. She went to the hall but did not see any staff around. Witness 3 did not go look for staff or ask any staff to come help her. Witness 3 stated while turning the resident away from her the resident started to roll off the bed and landed on the floor. The resident's bed was raised to a three or four foot height. In an interview on 5/27/14 at 10:20 am Witness 2 (Former Facility LPN) indicated she was called to the room because the resident was on the floor. Witness 2 "knew it was going to be bad because the CNAs change residents with the beds in the high position." When she got to the room the resident was face down on the floor and there was urine on the floor. Witness 2 got additional CNAs to help transfer the resident back to bed. A Hoyer lift sling was placed under the resident after she/he was rolled onto her/his back. The resident required two staff to assist with bed mobility but Witness 3 rolled the resident alone. In an interview on 5/27/14 at 10:45 am Staff 2 (DNS) indicated the resident had a similar fall from a roll out of bed with one staff, several years ago. The resident's care plan was updated at that time to reflect two staff assist required for bed mobility/positioning. The care plan was reflective of the appropriate assistance required and should have been followed. Witness 3 (Former Facility CNA) knew the resident required two staff to assist but chose not to get help.

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].#s 1, 2, 3 & 4) reviewed for bowel care. As a result, Resident 1 was hospitalized . Findings include: 1. Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. The 12/2012 Physician order [REDACTED]. The December 2012/January 2013 Physician order [REDACTED]. A 12/11/12 Call Documentation indicated the resident did not "regularly have constipation now" and noted the resident had loose incontinent stools. The facility requested the [MEDICATION NAME] be decreased to twice daily, which the physician approved. The December 2012 Vitals Report documented that from 12/9/12 through 12/12/12, (the same period when the the physician was notified regarding the [MEDICATION NAME]) the resident had no BMs (bowel movements), for a period of four days. According to the 12/2012 MAR, the resident did not receive PRN bowel care medications during the 12/9/12 through 12/12/12 timeframe. The January 2013 Vitals Report documented from 1/20/13 through 1/29/13, the resident only had one BM on 1/23/13, a period of 10 days. According to the January 2013 MAR, during the 1/20/13 through 1/29/13 timeframe, the resident only received [MEDICATION NAME] tablet on 1/23/13 and [MEDICATION NAME] suppository on 1/29/13. A 1/29/13 Progress Note disclosed the resident was awake, alert and appeared to be confused. The resident was noted to have a very distended abdomen, very firm to palpation with minimal bowel tones. A suppository and [MEDICATION NAME] were administered. A family member was contacted, who informed Staff 18, Agency LPN, the resident had been hospitalized for [REDACTED]." Staff 18 documented he attempted to give the resident the PRN [MEDICATION NAME], but it was not in stock. The physician was contacted, who ordered the resident be transported to the hospital. The 1/29/13 facility Incident Investigation disclosed staff interviewed stated they were aware of the resident's [MEDICATION NAME] order if she/he had no BM in two days, but had not administered the medication. Not all staff recalled receiving a bowel care list due to a 1/26/13 illness in the facility. The facility determined there were several system issues identified. The 1/30/13 emergency room Report noted the resident presented with a reported lack of BMs for the past six days with abdominal distension. The resident had emesis and shortness of breath. The Final Clinical [DIAGNOSES REDACTED]. In interview on 3/1/13 at 1:33 pm, Staff 6, RN, stated she did not recall specific details regarding the December 2012 timeframe of no BMs. Staff 6 stated the resident had chronic problems with her/his bowels and could not have regular BMs. In interview on 3/1/13 at 2:32 pm, Staff 20, CMA, stated she did not recall specific details regarding the December 2012 timeframe of no BMs. Staff 20 stated before the resident went to the hospital, the facility had a lot of people sick with an illness. On "one day", the resident was on the bowel care list, she could not get to treating the resident and passed the information to the evening shift. In interview on 3/1/13 at 1:50 pm, Staff 9, LPN, stated bowel care was an on-going problem for Resident 1. Staff 9 stated she worked with Resident 1 on 1/26/13 and 1/27/13. Staff 9 stated she did not remember the resident being on the list those days. In interviews on 2/25/13 at 3:23 pm and 3/5/13 at 8:45 am, Staff 19, CMA, stated she could not recall any details regarding the December 2012 timeframe of no BMs. Staff 19 stated on 1/26/13, Staff 19 stated she received the bowel care list, but did not look at the list due to an illness going on in the facility at the time. Staff 19 stated on 1/29/13, she got the bowel care list, which noted the resident had not had a BM for four days. The resident's stomach was "big" and she/he complained of pain, per her/his norm. In interview on 3/1/13 at 11:43 am. Staff 18, Agency LPN, stated on 1/29/13 when he checked Resident 1, her/his stomach was very firm, she/he was "pretty lethargic" which was different for the resident and she/he had not had a BM for "several days." Staff 18 stated the resident had an order for [REDACTED]. In interview on 2/25/13 at 3:43 pm, Staff 4, RNCM, stated in December 2012, staff had reported to him the resident had diarrhea related to the extra dose of [MEDICATION NAME], but he had not checked the bowel record himself. Staff 4 stated the resident was to receive [MEDICATION NAME] if she/he had no BM for two days and the resident did not receive the medication as ordered in January. 2. Resident 3 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. The facility's Bowel Protocol noted if a resident had not had a BM in three days, Milk of Magnesia was to be administered. If not effective, a [MEDICATION NAME] suppository, followed by a Fleet's enema was to be given. "Residents who are noted for having small bowel movements will be assessed for constipation." The December 2012/January 2013 Physician order [REDACTED]. According to the December 2012 Vitals Report, from 12/26/12 through 12/30/12, Resident 3 only had a small BM on 12/27/12, a period of five days. According to the December 2012 MAR, the resident did not receive PRN bowel care medications during the 12/26/12 to 12/30/12 timeframe. There was no documented assessment in the clinical record at the time of the survey of the resident's bowel status, including only having a small BM. According to the January 2013 Vitals Report, from 1/15/13 through 1/18/13, the resident had no BMs, a period of four days. According to the January 2013 MAR, the resident did not receive PRN bowel care medications during the 1/15/13 through 1/18/13 timeframe. In interview on 2/25/13 at 2:00 pm, Staff 3, RNCM, stated Resident 3's PRN bowel care physician orders [REDACTED]. In interview on 3/1/13 at 1:56 pm, Staff 25, RN, stated Resident 3 took himself/herself to the bathroom and reported results to staff. Staff 25 stated she did not recall any details of the December 2012 timeframe. Staff 25 stated she did not think she completed an assessment when the resident only had a small BM. In interview on 3/4/13 at 4:35 pm, Staff 23, LPN, stated he did not recall details of the December 2012 and January 2013 timeframes. Staff 23 stated he could not recall doing an assessment of the resident's bowel status, including only having a small BM. In interviews on 3/4/13 at 4:47 pm, 5:02 pm, 5:10 pm and 5:26 pm with Staff 14, RN, Staff 21, RN, Staff 28, RN and Staff 27, CMA, they stated they could not recall specific details regarding the December 2012 and/or January 2013 timeframes. 3. Resident 4 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The facility's Bowel Protocol noted if a resident had not had a BM in three days, Milk of Magnesia was to be administered. If not effective, a [MEDICATION NAME] suppository, followed by a Fleet's enema was to be given. "Residents who are noted for having small bowel movements will be assessed for constipation." The December 2012/January 2013 Physician order [REDACTED]. According to the 12/2012 Vitals Report, on 12/9/12 and 12/10/12 the resident only had small BMs, with no documented BMs on 12/11/12 or 12/12/12, a period of four days. According to the December 2012 MAR indicated [REDACTED]. There was no documented assessment in the clinical record at the time of the survey of the resident's bowel status, including the small BMs. According to the 1/2013 Vitals Report, from 1/23/13 through 1/26/13, the resident either had small BMs or no BMs, a period of four days. According to the January 2013 MAR indicated [REDACTED]. There was no documented assessment in the clinical record at the time of the survey of the resident's bowel status, including the small BMs. In interview on 2/25/13 at 2:00 pm, Staff 3, RNCM, stated the resident's bowel status related to the small BMs needed to be assessed to ensure the resident was not constipated. Staff 3 stated Resident 4 should have received the PRN bowel care medications. In interview on 3/4/13 at 10:45 am, Staff 17, LPN, stated she did not recall the resident not having BMs during the December 2012 and January 2013 timeframes. In interviews on 3/1/13 at 1:56 pm, 2:18 pm and 2:32 pm, 3/4/13 at 4:35 pm and 4:47 pm and on 3/5/13 at 8:45 am, Staff 25, RN, Staff 26, CMA, Staff 20, CMA, Staff 23, LPN, Staff 14, RN and Staff 19, CMA, stated they could not recall specific details regarding the December 2012 and January 2013 timeframes. 4. Resident 2 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The February 2013 Physician order [REDACTED]. According to the February MAR indicated [REDACTED]. There was no documented evidence in the clinical record at the time of the survey the physician had been informed the resident had not received the [MEDICATION NAME] during the month of February. In interview on 2/25/13 at 2:27 pm, Staff 1, RNCM, stated she was not aware the resident had not received the [MEDICATION NAME] for the entire month of February and should have been informed. In interview on 3/1/13 at 2:00 pm, Staff 12, RN, stated Resident 2 had refused the [MEDICATION NAME] for the last month and thought it was reported to Staff 1 and the physician. Staff 12 was unable to locate documentation of the physician being notified of the resident's refusals.